331880702-12-3-2021-18-AS-NBRN-C9RPJQ-20211216102154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880702
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:14:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2021 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210806114345

FACILITY NAME:	MIRAGE ELDERLY CARE		FACILITY NUMBER:	331880702
ADMINISTRATOR:	THEOBALD, VICTORIA		FACILITY TYPE:	740
ADDRESS:	1 CALAIS CIR		TELEPHONE:	(760) 328-6400
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	6	CENSUS: 3	DATE:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Victoria Theobald, licensee/administrator		TIME COMPLETED:	12:13 PM

ALLEGATION(S):

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Resident not receiving prescribed medication

INVESTIGATION FINDINGS:

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On 12/3/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the finding to the above allegation. The LPA met with licensee Victoria Theobald, explained the nature of the visit and was granted entry.

The investigation, which consisted of interviews and document review revealed the following:
It was reported that Resident 1 (R1) was not receiving medication for a rash per physician's orders. Facility document review indicates R1 was given Nystatin cream as well as hydrocortisone cream on 8/3/21, 8/4/21 and 8/5/21 two to three times per day by the facility staff. A review of R1's hospice file, hospice staff administered a Benadryl cream on 8/4/21. *** continued on LIC 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210806114345

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIRAGE ELDERLY CARE	FACILITY NUMBER: 331880702
	VISIT DATE: 12/03/2021

NARRATIVE

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*** Continued from 9099***

On 8/5/21 hospice administered a hydrocortisone cream and documented that the Benadryl cream needed to be refilled. On 8/6/21, hospice applied hydrocortisone cream. Documentation indicates hospice visits began on 8/3/21, it appears that hospice was responsible for applying the cream and failed to do so on 8/3/21 and 8/4/21. Due to conflicting information, the LPA was not able to corroborate the allegation that the licensee did not provide R1 with the prescribed medication.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted where this report and LIC 811 were provided to Victoria Theobald.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

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